Virilizing and Feminizing Adrenal Tumors

- Rare
- usually symptomatic

>80% are malignant
- almost all feminizing tumors malignant
- 50% of virilizing tumors are malignant

- because they are so rare, testing for sex hormone excess during work-up of incidentaloma should only be done if there are clinical signs of virilization or feminization

Diagnosis:
- Virilizing tumors: serum testosterone, serum dihydroepiandrostenedione, 24 hr urine 7-hydroxysteroid, 24 hr urine 7-ketosteroids (serum androgens and 24 hr urine keto-steroids suppressed if ovarian cause)
- dexamethasone suppression test can differentiate between adrenal and ovarian cause
- Feminizing tumor: serum estrogen and suppressed FSH, LH and gonadotropins confirm feminizing adrenal tumor (as opposed to testicular tumor)
- CT scan can generally localize a tumor

Consider that most are malignant when deciding if going to attempt laparoscopically

Adrenal Cushing's syndrome

Cushing's syndrome: caused by glucocorticoid excess
- central obesity, hypertension, moon facies, easy brusibility, weakness, depression, polyuria, glucose intolerance and diabetes

Gluccocorticoid secreting lesiosn:
- adrenal: adenomas, hyperplasia, adrenocortical carcinomas
- pituitary: adenomas, hyperplasia
- ectopic: SCLLC, bronchial carcinoid tumors, thymomas, pancreatic islet cell tumors

Diagnosis:

- elevated 24-hour urinary free cortisol most sensitive and specific test

- if 24 hour urine is negative formal low-dose dexamethasone suppression test can be performed

Important distinction during work-up:
- ACTH dependent or independent (adrenal adenoma and candidate for resection)
- measure plasma ACTH levels: should be low in ACTH independent tumors
Imaging:
- CT or MRI both can be used for localizing the tumor
- if pituitary or ectopic lesion suspected then imaging of head/chest may be warranted

Pre-op considerations:
- treat with stress-dose of steroids: taper slowly (the contralateral adrenal will be suppressed from pre-operative excess steroid secretion)
- pre-op antibiotics (due to immunosuppression from steroids)

TReatment:
- surgical resection of bilateral hyperplasia is indicated in this disease
- patient will requirer lifetime glucocorticoid and mineralocorticoid replacement (Florinef 0.1mg qD)

Aldosteronoma

Classic triad of Conn's syndrome:
- Hypertension
- Hypokalemia
- Polyuria

Diagnostic test is PAC:PRA >30
- PAC: plasma aldosterone concentration
- PRA: plasma renin activity
- second confirmatory test is an aldosterone stimulation test (positive if urinary aldosterone level elevated during a saline infusion)

Workup: adenoma vs. hyperplasia
- important step in working patient with suspected aldosteronoma is to determine if you are dealing with a unilateral adrenocortical adenoma (2/3 of patients) or bilateral hyperplasia
- other very rare causes include adrenocortical carcinoma, angiotensin II responsive adenomas, familial hyperaldosteronism type I and type II
- this can be done by imaging - CT scan may show a solitary lesion

Indications for selective adrenal vein catheterization:
- sampling of adrenal vein may be necessary to localize adenoma.  placement of catheter confirmed by increase in cortisol concentration as compared to IVC
- looking for ~5 fold increase in aldosterone compared to the other side
- indicated with there is adrenal hypertrophy, bilateral nodules, no lesions

Pre-operative considerations:
- patient begins spironolactone pre-operatively to control hypertension and normalize potassium levels.
- other antihypertensives are added as needed
- stop spironolactone immediately post-op

Iliac Aneurysms

Isolated ilaic aneurysms are rare
- most commonly associated with other aneurysms : found in 10-20% of patients with AAA

Difficult to detect clinically
- usually detected late and as a result mortality rates high

Recommendation is to repair iliac aneurysms once they are >3cm in size
- endovaascular options exist

Colonic Volvulus

Recurrence rate after endoscopic detorsion ranges from 30-90%.  Morbidity and mortality increases with each successiev detorsion.
- mortality of elective resection is low (1-5%), recurrence rate after resection low (~5%).
- If operative risk is too high - consider percutaneous endoscopic transcolonic tube placement

- recurrence rate of cecal volvulus is also high (20-40%): cecopexy or resection with primary anastamosis are eqully safe with similar recurrence rates (5-15%)

Antibiotic AHD

Pre-op Antibiotics:
- Ancef - for procedures not involving distal ileum, appendix, or colon (alt clinda + gent)
- for colon/

medical post article for antibiotic recommendations

- ancef provides gram positive prophylaxis, some gram neg coverage (but not great)
- for prophylaxis don't need to kill all bacteria

Colorectal prophylaxis
Ancef& Flagyl
If allergy
- clinda & Cipro or Gent and Flagyl
- cipro or gent & flagyl

SSI treatment:
Mild-Moderate community acquired infection ((SSI)
- Cefzaolin/flagyl
- ceftriaxone/flagyl
-cipro/levo and flagyl
-cefoxitin
-Moxifloxacin
Do NOt need enterococcal coverage, candida coverage, aminoglycocides

Severe community acquired infection:
- meropenem
-piptazo
-cipro/levo and flagyl
- ??

Healthcare associated intraabdo infections:
- meropenem/imipenem/doripenem
-piptazo
- ??

When do you need antifungal treatment:
- C. albicans - fluc
- other spp. - need caspofungin
- treat if you grow out of wound

anti-enteroccal
- if you grow from healthcare related infection
- amp, piptazo, or vancomycin

Appendix abx:
- with adequate source control, no need to extend abx beyond 4-7 days

Forearm compartments

Forearm has 3 major compartments:
- anterior (volar)
- posterior (dorsal)
- mobile was (includes brachioradialis, extensor carpi radialis longus, extensor carpi radialis brevis)